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New York Codes Rules Regulations (Last Updated: March 27,2024) |
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TITLE 22. Judiciary |
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Subtitle D. Forms |
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Chapter IV. Forms of the Family Court of the State of New York and Adoption Forms of the Family Court of the State of New York (cf. s205.7) |
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Subchapter A. Forms Authorized by Section 205.7 |
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Child Support Forms (Family Court Act Articles 4, 5-B) |
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UCS-111 Child support summary form: supreme and family court |
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UCS-111 (rev: 12/01) CHILD SUPPORT SUMMARY FORM SUPREME AND FAMILY COURT COMPLETE FORM FOR EACH BASIC CHILD SUPPORT OBLIGATION ORDER A. Court: □ Supreme □ Family B. County: ____ C. Index #/Docket #: ___ D. Date Action Commenced: _____/_____/_____ E. Date Judgment/Order Submitted or Signed: _____/_____/_____ F. # Of Children Subject to Child Support Order: _____ G. Annual Gross Income: 1. Father: $__ Mother: $ __ H. Amount of Child Support Payment: 1. By Father: $_ 2. By Mother: $ _ annually annually I. Additional Child Support: (Circle as many as appropriate) By Father: By Mother: 1. Medical/Med. Ins. 1. Medical/Med. Ins. 2. Child Care 2. Child Care 3. Education 3. Education 4. Other 4. Other J. Did the court make a finding that the child support award varied from the Child Support Standards Act amount? (Circle one) 1. Yes 2. No K. If answer to “J” was yes, circle court's reason(s): 1. Financial resources of parent/child. 2. Physical/emotional health of child: special needs or aptitudes. 3. Child's expected standard of living had household remained intact. 4. Tax consequences. 5. Non-monetary contribution toward care and well-being of child. 6. Educational needs of either parent. 7. Substantial differences in gross income of parents. 8. Needs of other children of non-custodial parent. 9. Extraordinary visitation expenses of non-custodial parent. 10. Other (specify): L. Maintenance/Spousal Support: (Circle one) 1. None 2. By Father 3. By Mother M. Value of Maintenance/Spousal Support: $ ____ annually SUPREME COURT ONLY N. Allocation of Property: _% To Father _ % To Mother UCS-111 (rev: 12/01) NEW YORK STATE UNIFIED COURT SYSTEM SUPPORT SUMMARY FORM: FAMILY & SUPREME COURT (UCS-111) INSTRUCTION SHEET Prepare one report for each proposed judgment or final order granted pursuant to Article 4 or 5 of the Family Court Act and DRL § 240 and § 236(9)(b) which includes a provision for child support (including modification of order). SUBMIT COMPLETED FORM TO: Office of Court Administration Office of Court Research 25 Beaver Street, Room 975 New York, New York 10004 GENERAL INSTRUCTIONS: > ALL ITEMS MUST BE ANSWERED 10. If a number or amount in dollars is required and answer is none, write 0. 11. If a certain item is not applicable, write NA. 12. If the information is unknown or not known to the party filling out the form, write UK. 13. “mm/dd/yy” means “month/day/year”. SPECIAL INSTRUCTIONS FOR PARTICULAR ITEMS: G. Use gross income figures from the last complete calendar year. Do not include maintenance or child support as income. H. If the child suppport award is calculated weekly, multiply it by 52 for the annual amount; if biweekly, multiply it by 26, if monthly, multiply it by 12. M. If the maintenance award is calculated weekly, multiply it by 52 for the annual amount; if biweekly, multiply it by 26; if monthly, multiply it by 12. If the maintenance award calls for decreasing or increasing amounts (for example, a certain amount for five years and half that amount for another three years), then provide the average of the awards (total amount for all years divided by the number of years). NOTE: THIS INFORMATION IS CONFIDENTIAL AND WILL BE USED FOR STATISTICAL PURPOSES ONLY. IT WILL NOT BE RETAINED IN THE CASE FILE. |